More reader comments on "Can a comprehensive lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema?" (Evidence in Practice).

More reader comments on "Can a comprehensive lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema?":

In his March 2002 "Evidence in Practice" (EiP) article, the author had "decided to search for articles that document the effectiveness of comprehensive lymphedema management programs." After reading the article, I did not find any experimental evidence that supports the effectiveness of the program that he selected. Changes in girth measurements do not prove that the technique that was used has improved the lymphedema. To state that a technique has improved the lymphedema, one would need to examine the fundamental research conducted by the Bourgeois-Leduc team in Belgium (1,2) or by Jean Claude Ferrandez and colleagues in France. (3-5) In the field of lymphedema management, there is a search for evidence to support practice; we need to address this point in a thorough way.

Another point that I would like to make is that the literature search should not be restricted to one language as was the case in Megens and Harris, (6) one of the articles cited in the EiP article. At the beginning of their "Method" section, Megens and Harris report, "Because we are fluent in English only, the literature search was restricted to English publications...." (6(p1304)) In the EiP article, the author's exclusive use of the English language obviously reduced his chances of carrying out a complete literature review.

Furthermore, when the author describes his clinical decision, he does not mention whether he is trained in the techniques that he decides to use. If he had not been previously trained in these techniques, this is certainly also a point of concern. I believe the scientific method should not be limited to a theoretical approach to the subject but should also include practical training.

In his description of his clinical decision, the author says, "I decided to implement a comprehensive regimen that included massage...." His use of the term "massage," however, is misleading. The manual technique used in lymphedema management is manual lymph drainage. (7)

Moreover, Ciccone is mistaken when he says, "Compression garments in reducing limb size in people with lymphedema...." A compression garment may reduce the size of an edematous limb, but not a lymphedematous limb. Compression garments maintain the reduction of lymphedema produced by using other techniques such as manual lymph drainage and multilayered bandaging. The Leduc team has demonstrated experimentally the effectiveness of the Leduc methods of both manual lymph drainage and multilayered bandaging. (1,2)

The author states that he will use "isometric exercises ... to facilitate lymph drainage via the muscle pump." Leduc et al (2) have demonstrated experimentally the ineffectiveness of isometric exercises on lymphatic flow. Isometric exercises enhance the lymph flow when performed on a limb with multilayered bandaging done according to the Leduc method and not when performed on a limb with compression bandaging.

The last paragraph of the EiP article says, "The issue of infection was never really addressed by the literature. I could not find any information that directly supported the use of physical therapy as a means to reduce the incidence of infection in people with lymphedema." If he had searched the literature using the following search terms for infection of the lymphatic system--dermatolymphangioadenitis, cellulitis or lymphangitis--he would have found the direct answers to his questions. (8,9)

The author has shown a certain determination in seeking an answer to his clinical question. He would have certainly achieved his goal of finding scientifically proven evidence more completely if he had been able to extend his search to other languages. In any case, I do not believe that a theoretical approach to his question was sufficient. Such a clinical question must be answered by the clinical expert. Expertise implies evidence-based and research-based knowledge.

Anne-Marie Vaillant-Newman, PT
Director
Pacific Therapy Education Inc
PO Box 892752
Temecula, CA 92589-2752

References

(1) Bourgeois P, Leduc O, Leduc A. Manual lymphatic drainage: scintigraphic demonstration of its efficacy on colloidal protein reabsorption. In: Partsch H, ed. Progress in Lymphology: Proceedings of the XIth Congress of the International Society of Lymphology, Vienna, Austria, 24-27 September 1987. Vol. 11. New York, NY: Excerpta Medica; 1988:551-554.

(2) Leduc O, Bourgeois P, Peeters A, Leduc A. Bandages: scintigraphic demonstration of its efficacy on colloidal proteins reabsorption during muscle activity. In: Nishi M, Uchino S, Yabuki S, eds. Progress in Lymphology: Proceedings of the XIIth Congress of the International Society of Lymphology, Tokyo, Kyoto, Japan, 27 August-2 September 1989. Vol. 12. New York, NY: Excerpta Medica; 1990:421-423.

(3) Ferrandez JC, Vinot JM, Serin D, Felix-Faure C. Evaluation lymphoscintigraphique de la technique du drainage lymphatique manuel: apropos de l'exploration de 47 lymphoedemes secondaires du member superieur. Les Annales de Kinesitherapie. 1995;22(6):253-262.

(4) Ferrandez JC, Vinot JM, Serin D. Validations lymphoscintigraphiques dues aux contentions semi-rigides dans le lymphoedeme secondaire du member superieur. Les Annales de Kinesitherapie. 1994;21(7):351-358.

(5) Ferrandez JC, Vinot JM, Serin D. Evaluation comparative lymphoscintigraphique du drainage lymphatique manuel et de la pressotherapie sur l'oedeme du member superieur secondaire au traitement d'une tumeur mammaire. Les Annales de Kinesitherapie. 1990;17(7/8):360-362.

(6) Megens A, Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Phys Ther. 1998;78:1302-1311.

(7) Foldi E. Massage and damage to lymphatics. Lymphology. 1995;28:1-3.

(8) Foldi E. Prevention of dermatolymphangioadenitis by combined physiotherapy of the swollen arm after treatment for breast cancer. Lymphology. 1996;29:48-49.

(9) Leu HJ. Lymphedema and relapsing infections: histopathological findings in primary and secondary lymphedema, and in subjects without lymph vessels diseases. The European Journal of Lymphology and Related Problems. 1997-1998;6(23);78-82.

Editor/Author responds:

I thank Levinson et al and Vaillant-Newman for the opportunity to elaborate on key aspects of the Journal's "Evidence in Practice" (EiP) series.

EiP articles are not meant to imply a standard of practice, and the interventions used do not necessarily represent "the" singular or optimal method for managing the patients described in the articles. The purpose of EiP is to illustrate the process of searching a specific database to obtain and apply the evidence from the literature covered by that database. Levinson et al note that a thorough examination and evaluation is essential. I agree--but I also must emphasize that, in EiP articles, some details about the patient's background and the examination and evaluation are purposely truncated to focus on the literature search.

Levinson et al and Vaillant-Newman indicated that certain citations were not retrieved by my search. As explained in the article, I selected CINAHL because I wanted to cover the allied health and nursing literature. Again, the purpose of EiP articles is to show clinicians how to retrieve evidence that will guide their management of specific types of patients. This citation retrieval process is not analogous to an exhaustive literature search on a given topic. There is undoubtedly published information that is not indexed in CINAHL and that might pertain to the management of this type of patient. This information, however, does clinicians little good if they cannot access or interpret the data.

For instance, I speak and read English only; an article written in another language, therefore, would not help me answer this clinical question. In addition, information appearing in certain sources will be inaccessible (and therefore cannot be evaluated) if these sources are not indexed in a commonly used database. Sources such as textbooks and conference proceedings (eg, the Proceedings of the XIIth Congress of the International Society of Lymphology, a publication in which, Vaillant-Newman claims, Leduc et al demonstrate the effectiveness of their techniques) are not indexed in either CINAHL or MEDLINE.

Levinson et al are concerned that I did not select a regimen that they call complex physical therapy (CPT). I avoided using the term CPT in my clinical decision because that term tells us nothing about the actual interventions administered to the patient. Instead, I described the components of a regimen using terms that can be universally understood by physical therapists (eg, massage rather than manual lymph drainage, compression bandaging rather than Foldi technique). In fact, the regimen that I described includes all the components of what Levinson et al identify as CPT. Hence, it seems that our approaches differ primarily in the terms used to describe each component.

Most importantly, EiP emphasizes selecting interventions based on evidence obtained from the literature. The articles I retrieved in this case were published in peer-reviewed journals, they involved patients that were similar to my patient, and they described the interventions with sufficient detail that a physical therapist could replicate these interventions. The letter writers imply that their certification categorically enables a therapist to apply appropriate and skillful treatment and that anyone who is not certified is automatically unskilled. This type of insular thinking does little to advance the profession of physical therapy. I found no evidence to suggest that special training was required to apply these interventions or that outcomes were substantially better when patients were treated by therapists with advanced training. Moreover, it would be impossible to determine the skillfulness of an intervention without observing its application.

Finally, Levinson et al present references that they claim support the use of the regimen described as CPT. Vaillant-Newman also presents references to support the effectiveness of manual lymph drainage and multilayered bandaging and the ineffectiveness of isometric exercises. Neither Levinson et al nor Vaillant-Newman indicated exactly how these studies established evidence for the effectiveness or ineffectivness of the interventions they discuss. For example, which studies used randomized well-controlled trials with sufficient statistical power to prove conclusively that the regimen they advocate is the optimal treatment for the type of patient described in the EiP article? As clinicians, we would need this information to fully assess the claims of Levinson et al and Vaillant-Newman.

Charles D Ciccone, PT, PhD
Editor--Evidence in Practice and Reviews
Physical Therapy

?In the next Evidence in Practice: Charles Ciccone, PT, PhD, will seek answers to the question "Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder?" (Coming in January 2003)